Tuesday, July 01, 2014

Many people poring over the data still emerging from the ACA's first open enrollment season seem not to grasp the volatility of Americans' insurance status. Take Peter Suderman:

Kaiser’s survey finds that the majority of previously uninsured
lacked coverage for two years, and that 45 percent reported not
having coverage for five years. Which means that more than half of
the previously uninsured were covered at some relatively recent
point.

Now, many of those people clearly were having difficulty getting
coverage for some reason—perhaps as a ripple effect of the
recession, perhaps because of some other factor. But many of them
appear not to be completely uninsurable. These are not people who
couldn’t get insurance under any circumstance. They’re people who
didn’t have it for the last several years.

Obamacare’s supporters would no doubt say that the law was
designed to help those people just as much as it was designed to
help those who never had coverage at all. That’s an entirely
reasonable position. But when we talk about Obamacare’s coverage
effects, it’s important to be clear about who is being covered: a
sizable number of people who were already insured, as well as
people who were both eligible for coverage and covered at one
point, but had lost their coverage.

It's true that the ACA is designed to help the long-term uninsured. It's also designed to help the millions who fall out of and back into insured status every year. Last fall, healthcare scholars Rick Curtis and John Graves brought those millions into focus:

The relatively large number of people who will become eligible for
Marketplace coverage over the year due to changed circumstances is not
surprising in light of the historically dynamic nature of uninsured
status, as well as that of non-group coverage, in the U.S.

For example, a study by Mathematica Policy Research
found that 7.7 percent of non-elderly persons were uninsured for the
entire year, while on average 15.9 percent were uninsured in a given
month, and 27 percent were ever uninsured at some point during the
year. And most people enrolling in non-group coverage have only done so
for a limited period of time: During an average month, 5.3 percent of
the non-elderly population had non-group coverage, but only 2.1 percent
held non-group coverage for the entire year, and 9.7 percent had
non-group coverage at some point during the year. Finally, while
employer-sponsored insurance (ESI) is substantially more prevalent and
stable, 56.4 percent held ESI for the entire year, and 76.1 percent held
ESI at some point during the year.

Let these numbers sink in. More than three times as many Americans are uninsured at some point in a year as are uninsured for an entire year. More than a quarter of Americans under 65 find themselves uninsured at least briefly in any given year. More than a quarter of those insured by their employers at a given moment don't hold (or haven't held) that particular coverage for the entire year.

That data, from the Mathematica study (published in 2009), is a snapshot from 2001, a period of near-full employment: employer-sponsored coverage covers a smaller percentage of the population today. Some additional snapshots from the study's analysis of the insurance status of 30,000 households in the three years prior to January 2001: while 17.6% were uninsured at the end point, 35% had been uninsured at some point during the prior three years. Of those, 23% were uninsured for four months or less, and over 40% for a year or less (almost 60% were uninsured for a year or more).

In other words, while long-term lack of insurance has been a major problem, so has short-term lack of insurance. Similarly, while lack of insurance is concentrated among lower income Americans, it's far from a rare occurrence among the middle class. The Mathematica study highlights the extent of risk to which the non-poor as well as the poor are exposed:

Family income relative to the poverty line is the single strongest predictor of insured status when measured at a point in time. The uninsured rate in January 2001 ranged from a high of 42 percent among people below poverty to a low of 5 percent among people above 400 percent of poverty. We find that relative income in the first year of the 2001 panel is very strongly associated with coverage over the duration of the panel as well. The fraction ever uninsured was 68 percent among persons below poverty in the first year and declined to 14 percent among persons above 400 percent of poverty. Nevertheless, the substantially greater numbers of higher-versus lower-income persons yielded a surprising result—namely, that persons with family incomes above 200 percent of poverty in 2001 accounted for just over half of the ever uninsured and just over half of new insured and uninsured spells.

So yes, Peter Suderman, let's be clear about "who's being covered by Obamacare." All of us are. That is, all of us are assured -- or would be, if 20something states had not rejected the Medicaid expansion -- that affordable coverage will be available if we are subject to the substantial shocks that our employer-based insurance system subjects us to.

Some of those earning over 400% of the Federal Poverty Level and unencumbered by pre-existing conditions (or family members with them) will pay more for insurance in the individual market than they would have without the ACA. They are compensated by the assurance that if their income drops, or a family member develops a preexisting condition, insurance will remain affordable -- and free of the lifetime and annual caps, hidden exclusions and arbitrary rescissions that were common prior to the law's enactment.

It's true, too, that in the law's first iteration "affordable" in some cases means barely or marginally affordable, and even -- in the case of the "family glitch" -- unaffordable. That glitch -- stipulating that employer-sponsored insurance is "affordable," disqualifying an employee from obtaining subsidized coverage on the ACA exchanges, if individual rather than family coverage costs 9.5% or less of family income -- should be easily fixable. And it should be a given that members of Congress of both parties would work to improve a major, multi-faceted bill reforming one sixth of the U.S. economy. The law is instead threatened with ongoing sabotage. But of itself, it's a quite credible start toward universal coverage.

About Me

I'm a freelance writer and media consultant with a lasting interest in how democracy works, how it malfunctions and self-corrects. Since fall 2013 I've focused increasingly on the unfolding drama of Affordable Care Act implementation and health reform more generally.
I have a Ph.D. in medieval English literature and a propensity to parse the rhetoric and logic of our political leaders as well as that of media pundits and scholars who jump into the national debate. I wrote a dissertation on the remarkably humane and subtle medieval English anchorite Julian of Norwich, a mystic nun whose knack of squaring circles and framing paradoxes reminds me a little of our current president. A sampling of that work (mind the google gaps) is here: http://bit.ly/OzwsrR